George A. Woodward

Creating a leaner pediatric emergency department: how rapid design and testing of a front-end model led to decreased wait time.

Objective To use Lean methodologies and the Model for Improvement to rapidly redesign and pilot test a new pediatric emergency department (ED) front-end model that reduces time to a licensed independent provider to 30 minutes or less. Methods Lean improvement methodologies were applied during a 5-day multidisciplinary model of care redesign event. The new ED front-end model of care included: (1) placement of a registered nurse in the lobby; (2) direct patient rooming with elimination of traditional triage; 3) early documentation of home medications; 4) Team-based immediate assessment; 5) “early Initiation” providers to place orders when a team was not available. An observational, cohort controlled before-and-after study design was used. The new model was tested over 2 pilot periods and compared to a similar period of control days, defined as the “current state.” Results The ED census and patient acuity were similar during both pilot periods. Eighteen patients were included in pilot 1, and 80 patients were included in the expanded second pilot. Patients seen within 30 minutes improved from a baseline of 33% to 93% in pilot 2. Time to a licensed independent provider, to a room, and to visual assessment by a nurse all decreased. The largest decrease was in median time to provider, from 43 minutes in the current state to 7 minutes during pilot 2. Conclusions Rapid process improvement methodology was used to design and test a front-end model that reduced patient waiting time. Our experience demonstrates the feasibility of employing Lean principles and the Model for Improvement in actual practice environments to rapidly improve care delivery processes in pediatric emergency departments.

Improving Patient Flow Using Lean Methodology: an Emergency Medicine Experience

Opinion statementIn today’s rapidly changing health care milieu, organizations are expected to continuously improve the quality of care delivered to an expanding population of patients. To do so, they need a framework for developing, testing and implementing changes. Lean provides a methodology to engage workers and leaders to identify waste in a process, develop standards, implement a change, assess the results of that change, review next steps, and repeat the process. This can be successfully accomplished in the highly variable world of emergency medicine and can help health care providers be more productive, engaged, and satisfied while enabling patients to receive the value-added care they want and expect. Successful implementation of Lean or any other improvement framework requires that the hospital and medical leadership are all strong supporters of the methodology, speak the same process improvement language and are able to generate support and resources for operation-wide forward movement.

Rapid Electronic Provider Documentation Design and Implementation in an Academic Pediatric Emergency Department.

Background Many emergency departments are transitioning from paper charting to full electronic health records, which include both computerized provider order entry and provider documentation. Implementation of electronic provider documentation (EPD), in particular, has been challenging. Known benefits include legibility, medicolegal and compliance safeguards, and improved access to patient charts. Offsetting these benefits may be reductions in efficiency, patient throughput, and less provider-patient interaction. Methods We used a rapid design process coupled with Lean principles, simulation, aggressive training, and continuous process improvement to design and implement a novel EPD system with real-time voice recognition dictation in the pediatric emergency department (PED). We used statistical process control methodologies to compare mean PED lengths of stay (LOSs) for admitted and discharged patients before and after EPD GoLive. Results We were able to design, test, train, and implement a novel EPD to the PED within 7 months. There was special cause variation, with a 2.7% (5-minute) increase in overall LOS after EPD implementation. There was a temporary 9.3% (15-minute) increase in discharge LOS for 6 weeks after GoLive, with a subsequent return to a new baseline of 4.3% (7-minute) increase. There were no significant changes in admission LOS. There was overall consistent use of the voice recognition system several months after EPD rollout. There have been improving rates of compliance with chart completion over time, as a result of easier tracking and electronic reminders to complete. Conclusion Despite the inherent challenges involved in transitioning from paper charting to EPD, our study showed that an academic ED, EPD, can be rapidly designed and implemented while not significantly negatively impacting ED metrics such as LOS. We had consistent use of the voice dictation system after implementation. Time spent documenting after clinical shift was not reliably captured and is an important area of future research for successful EPD implementation.

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department

Study objective: Patient handoffs at shift change in the emergency department (ED) are a well‐known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. Methods: A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping “waterfall” shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. Results: A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. Conclusion: This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single‐physician coverage.

Miscellaneous Causes of Pediatric Chest Pain

This article describes some of the miscellaneous etiologies of pediatric chest pain that are important to recognize early and diagnose. Up to 45% of pediatric chest pain cases may elude definitive diagnosis. Serious morbidity or mortality is infrequent. Accurate diagnosis of more obscure causes may help to avoid unnecessary emergency department evaluation and cardiology referral, while also alleviating the concern and stress families and patients experience when dealing with chest pain.

Radiologic procedures, policies and protocols for pediatric emergency medicine

Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.